Detecting Child Abuse in the Emergency Department

When there is concern for physical abuse, the physical examination should be completed with the child undressed (in a gown), with specific attention to the skin, scalp and fontanel, mouth and oral cavity (including frena), ears, genitalia, and growth chart.
Any injury in a preambulatory child, including bruises, mouth injuries, fractures, and intracranial or abdominal injury, should raise concern for abuse.
The “TEN 4” rule: bruising of the Torso, Ears, or Neck in children <4 years old and any bruising in children <4 months old should raise concern.
Radiographic skeletal survey should be performed using proper technique for children <2 years old with concern for abuse. Repeating the skeletal survey 2–3 weeks later can identify additional fractures that were not seen initially.
Young (<2 years old) siblings and household contacts of abused children should be examined for abusive injuries and undergo skeletal survey.
Infants evaluated for physical abuse may benefit from neuroimaging even if they don’t have neurological symptoms.
Retinal examination is indicated for children with concern for abusive head trauma but may not be indicated for children without intracranial injury.
Health care providers with a reasonable suspicion of physical abuse have a legal mandate to report their concern to child protective services.